Manju, a 26 year-old IT professional working long hours in Kochi, developed a nagging pain in the center of her chest. She didn’t have the time to consult a doctor, and she did what many people do in such situations: Manju decided to search the Internet for a solution. Her Google search left her convinced that all of her symptoms pointed to terminal heart disease, and that her days were numbered. She was no longer able to focus on her project, became irritable and frequently showed up for work tired from lack of sleep. She was already worrying about how her dependents would cope in her absence.

Alarmed at her change in demeanor, her colleagues brought her to a doctor. After taking a detailed history including questions on her lifestyle, her doctor ordered a couple of blood tests, and told her that she had acidity from irregular meal timings and excess consumption of cola. Within two weeks, Manju was back to her cheerful healthy self.

Manju’s story is a typical case of Cyberchondria, defined as "the excessive use of Internet health sites to fuel health anxiety."

In this case, the difference between Google and the doctor was that while the Internet provided Manju a long list of the possible diagnoses, the doctor was able to dig out pertinent lifestyle clues from her history using medical knowledge, correlate with past experience of similar patients, and arrive at a single diagnosis.

Moral of the story: Google could bring you loads of information but lacks the ability to think. Even after the arrival of the so-called AI (artificial intelligence) that has made computers smarter, the thinking capacity of the human mind cannot be matched by machines at this time.

With the universal availability of smartphones, the number of people searching the Internet for information is skyrocketing, as is the quantity of information available online. Medical queries are a common reason to access Internet; some of the leading tech firms in India have reported that a majority of their employees routinely use Google to diagnose themselves.

The question is – is the Internet a reliable way to diagnose disease? Who is better: the doctor or Google?

This article is written to analyses the pros and cons of using the Internet for self-diagnosis. The first section explains how the Google search engine works. It will feel similar to taking a long-overdue, behind-the-scenes peek into the kitchen of your favorite restaurant (you always loved the food, but never bothered to check the kitchen out). The next section takes a candid look at how the doctor’s mind works, followed by a discussion of how to best harness the power of the Internet for one’s health queries, but yet remain safe.

How much knowledge is out there?

As an extension of Moore’s law of 1965 that states that the number of transistors per square inch on integrated circuits will double every 18 months, the amount of information on the Internet doubles every 13 months.

Till the 1950s, medical knowledge took 50 years to double, and by 1980, it did so every 7 years. It is estimated to double every 73 days by 2020.

What is a Google search?

Google, already a household term, has even gained entry into the Oxford English dictionary as a verb that means searching for information using Google search engine. Knowledge, which once upon a time was confined to books occupying dusty library shelves, has now become universally available -- for free. Google has even changed the way people look at knowledge. If the human brain was a computer, Google is now seen as its portable hard drive that stores data – almost as a substitute for non-essential human memory.

With time, improvements have occurred in the way Google performs a search. RankBrain is such an artificial intelligence system that helps understand a user’s questions even in natural language, generating increasingly relevant results.

Knowing how to select effective keywords for the specific query we have in mind is a way to improve the search results. For example, using double-quotes will help identify the exact phrase on a web page: “common causes of headache”. On the Google homepage, going to options > advanced search will open up a world of search options including searching by region, language or file type.

How does a Google search really work?

If the Internet was a textbook, Google has created an index that covers most of it – an estimated 60 trillion web-pages (that is 6 followed by 13 zeroes). When a search is ordered, Google in fact searches from this index, and not the actual Internet.

To better understand how Google search works, let us look at the example of someone who wants to start an online business of selling leather bags. After making sure he has the right inventory, the seller creates an attractive web page displaying his products, which will allow customers to search for, locate and buy online.

The web-pages are created with plenty of specific keywords (tag-words) embedded, like “leather”, “hand-bag”, vanity bag”, “Laptop bag” etc. that are commonly used search words by potential customers. Attractive photographs - each bearing an digital signature of the web page - are also added. Thus, anyone who finds the photos or uses these keywords during an Internet search is led to the homepage of that business - a process not unlike putting out attractive bait while hunting.

Google’s custom software called spiders or Google-bots are constantly crawling the web, following links from page to page, identifying new content and updating the index. This new page also eventually gets noticed, and finds a mention in Google’s index of Internet pages.

The problem is, there could be hundreds of similar businesses. How to get this site to be noticed first by a potential customer who is searching for a leather bag? This is where search rankings come in.

When a customer types a keyword, e.g. ‘leather bag’ in the Google search-box, Google’s search algorithm tries to interpret what the user has in mind, and then pulls up the web-pages containing that keyword from its vast index. These are listed in a particular order, also called ranking of results.

As only the first two or three search results get noticed by the customer, getting top ranking during a search is important for this new business to survive.

The search algorithms can be influenced by a process called SEO (search engine optimization), which depends on over 200 different ranking parameters pertaining to the web-page. The nature of these parameters is a closely guarded secret that gets frequently updated, helping Google deliver what it thinks is the most relevant content during a keyword search, while outwitting rogue web-developers from artificially inflating the importance of their web page Examples of such parameters include the distribution of the keyword on that page, and the number of external links.

To attain a high ranking, the new web page is worked upon and ‘optimized’ by an SEO professional. If a high ranking was achieved, the new business is more likely to succeed as more people will visit the site following a keyword search.

SEO professionals stay up-to-date with the latest trends in these ranking parameters, and are expected to follow ethical guidelines. Incidentally, faulty SEO strategies can lead to Google banning the web page Even a large corporation like BMW was banned by Google in 2006 because of apparently unethical SEO strategies, a case involving the use of ‘doorway pages’ - a practice that presented different page contents to the search engine and the user.

The situation about searching for health information online is no different. The user will be led to those websites that best conform to Google’s 200 ranking parameters, and that is determined more by the skill of the SEO professional and web page developer than the quality and credibility of the information on that page.

Health information may get uploaded by a private individual, a news-portal, scientific society, or frequently, by a business hoping to attract customers. It follows that all of the information available is not of good quality. There will no doubt be commercially biased information, which lures readers into purchasing the product touted by the business, for example, a weight-loss pill.

In other words, though a marvel of science, a Google search need not always retrieve the most accurate information.

What about paid ads on Google that appear during a search?

These are displayed above and to the right of the ‘organic’ (genuine) search results; and those users who can’t tell a sponsored ad from a genuine search result will invariably click on the sponsored link. The advertiser pays Google every time a user clicks on the ad.

How did these ads get up there? As Google’s spiders that crawl the web for genuine results can’t be influenced by money, those who wish to get their business noticed for a price can upload the new web page as a paid advertisement. The size of the payment, which also involves bidding, will decide how far up on the ads rankings the particular ad figures, and for how long it gets displayed.

Try typing the keyword “leather hand bag” into the Google search-box on different days to get a feel for the whole process.

Why is Internet self-diagnosis not a good idea

Though the Internet provides the meaning of technical terms, understanding medical literature in the true sense is not possible for a lay person without a background of structured training in health care.

The best way to explain this is to observe the case of learning a new language prior to visiting a foreign country. Using a handbook, it is possible to understand the meaning of most of the commonly used words, so that basic ideas can be expressed without difficulty. However, knowledge of words is not the same as knowing the language. Try reading a novel or other literary piece with that basic knowledge – it turns out to be extremely difficult. Thus, unless we actually know the language, we will find it impossible to understand (and express) complex ideas, metaphors, euphemisms, stylized phrases and slang – the factors beyond basic words use that make literary work so beautiful.

Similarly, Medicine is a language, and comprehending medical literature involves not only a knowledge of technical terms, but a deep understanding of all of these fine nuances including bio-statistics, that can only come from structured training and experience. Without such a background, a collection of mere words (technical terms) will be largely meaningless -- creating anxiety, confusion, sometimes even overconfidence in the reader’s mind.

An anxious mind lacks judgment, and can skip several steps in logical thinking, arriving at pessimistic and unrealistic conclusions. For example, a person who is already anxious about his headache and frantically searching on Google for causes of headache, might focus on the most serious cause of headache – a brain tumor, even though the web page might rightly indicate that migraine is more likely. In fact, for the same reason, many sensible doctors do not attempt to self-diagnose - they prefer consulting another doctor as they know how anxiety can cloud their own judgment.

For a patient, the very purpose of visiting the doctor is to reduce anxiety by obtaining clarity about one’s health condition. A good doctor can reduce anxiety just by listening patiently to the patient’s words, allowing the patient to vent. Once the diagnosis is explained, the uncertainty factor is removed; the patient’s mind becomes uncluttered. This is called closure, which brings on a sense of calm.

The Internet, being a machine without emotion or empathy, cannot achieve any of this.

Other downsides of using the Internet for self-diagnosis and treatment

1. The user is overwhelmed with a long and complex list of possibilities that gets pulled up by the search engine, as opposed to wise counsel by the doctor that simplifies the situation.

2. It is easy to fall prey to a scam artist hosting an attractive web page that lures the patient into purchasing unauthorized treatment modalities. Such pages, although low in quality of content, can be manipulated to score high on Google’s web page ranking algorithm by SEO experts.

3. Confirmation bias: It is possible to find an article that supports any theory that the patient might favor. For instance, a person with a drinking problem will selectively focus on articles that favor alcohol use. He fails to realize that one article or study does not mean the truth. Truth emerges one step at a time, from the collective experience of researchers worldwide.

4. Every keyword we type in the search-box is silently monitored by Google, in an attempt to send us an ad based on our profile. For example, a person searching on obesity might soon receive ads from sellers of weight-loss pills, many of which are banned and harmful. The user might also be directed to businesses in that locality that run a weight-loss program, legitimate or otherwise

5. Medical ethics on the Internet is not well-defined – anyone can post information and advertise magical cures with no valid research publications to support these claims. In contrast, the vast majority of doctors adhere to the established code of medical ethics.

6. Using the Internet to interpret lab test results without the clinical reasoning of a doctor can lead to unwarranted anxiety about serious illness.

Why do patients turn to the Internet for self-diagnosis?

The Internet is free for the most part, can be accessed from the privacy and comfort of one’s home, and is open 24/7. There is no need to book an appointment or take time off work. Many people have a blind trust for any printed information, and may believe all online information verbatim. Besides, the Internet provides anonymity and, last but not the least, does not make fun of the patient for posing an unorthodox query.

How does a doctor make a diagnosis?

In addition to having a deep understanding on the working of the human body, the doctor also knows about various diseases and their assorted symptoms. In addition, the doctor has experience: from his own patients from the past, and from the collective experience of other doctors learned during training, as well as from attending scientific seminars.

The most important distinction here is the analytical thinking capacity of the trained human mind that could not be replicated in any computer model yet. Although a website can generate an algorithm or probability lists on a symptom checker format, it cannot match the intuitive thinking (heuristic analysis) and deductive reasoning capacity of the doctor’s mind.

Experienced doctors can rule out most of the alternative diagnoses by simply taking a detailed history – many times even without performing tests.

There is no infallibility here - a doctor need not always get it right, for various reasons: the information provided might be incomplete, there may be limitations to do investigations, the typical manifestation of the disease might not have been present, or she simply might not have thought of that possibility. Not to forget the biological variability of the human body - no two of us are really alike, neither is our biology.

Good doctors try to minimize this fallibility by educating the patient to return if symptoms persist, and by scheduling pertinent investigations in a step-wise manner.

It is not just the diagnosis or a pill that we need the doctor for. Medical decision-making is much more than writing a prescription. In addition to scientific thinking, it involves a varying mix of empathy, kindness, ethics, morality, culture, spirituality, reassurance and effective communication.

For example, when faced with a dilemma involving serious illness in the family, an experienced and compassionate doctor will be able to help make a practical decision customized to the situation, after analyzing innumerable variables. Even a decision not to give any treatment is an example of such a decision. (in some situations, treatment can be worse than the disease)

Medicine is not an exact science. Not all doctors share the same treatment approach, and not all patients with the same condition can be treated by the same medications.

If no improvement occurs after initial treatment, it would be sensible to go back and let the doctor know about the apparent lack of response. This is a better option than Googling the medications and the diagnosis offered by the doctor and becoming more confused.

Alternatively, a second opinion could be sought. Naturally, the doctor offering the second opinion will be at an advantage over the first doctor as he has a chance to know what course of treatment did not work, and what investigations had already been performed.

It is worthy of mention here that the general practitioner is the best person to approach first for most symptoms except emergencies. They have the broadest range of experience and knowledge - in contrast to the specialist, who typically knows more about his area of expertise, but less about the rest.

What then, can the patient use the Internet for?

Although not a great tool for self-diagnosis, the Internet offers a wide array of services from the patient’s perspective. Those suffering from certain chronic conditions such as colitis, asthma or hypertension can read patient-related information and take control of their disease. Worldwide, medicine has evolved from a patriarchal system of yore where the doctor dispensed treatment, to a mutually supportive model where the doctor and the patient work together to cope with the illness.

Patients can learn more about procedures that they are about to undergo, for example, cardiac catheterization, colonoscopy or MRI scan.

Those suffering from uncommon conditions like Lupus and Sickle cell disease can join online forums and support groups of such patients worldwide, learn from other patients’ experiences and discover solutions to their own, with their doctors’ guidance.

What do doctors need to do about this problem?

Doctors need to understand that Internet medicine is here to stay, and more people will be using it as time goes on. They must accept the idea that the next patient who walks in could have done several hours of reading about the diagnosis or treatment, and learn to respond empathetically.

Depending on their area of expertise, the doctor could suggest professional websites that have a patient’s section. Brochures with good quality information can be given out. Informing the patient of a few of the common side-effects of medications used, and an approximate time-course of the illness would help reassure the patient better. The doctor could remind the patient to check back with him if the condition does not improve as expected, so that the patient does not have to depend on the Internet.

Doctors who work within the constraint of large patient-loads must customize their patient interview style to the situation, so that critical pieces of information are not missed out. Unfortunately, as science advances and health care becomes an industry, the art of medicine gets forgotten. Listening ability, ethics, communication skills and gentle bedside manners are essential attributes of a good doctor, perhaps as important as updated and unbiased scientific knowledge.

Those with an undiagnosed symptom are better off consulting a qualified doctor than attempt self-diagnosis using a Google search. The Internet can help patients in many other ways, as outlined above. Venturing to read medical literature without structured training in medicine can lead to premature, erroneous conclusions.

(The author is a Senior Consultant Gastroenterologist and the Deputy Medical Director, Sunrise Group of Hospitals, Kochi. His column, Everyday Health, will appear every alternate week)